Use of electronic health records for patients with diabetes improves achievement of care and outcomes targets, researchers found.

Action Points

Explain that diabetes standards of care and outcomes were significantly improved among practices that used electronic -- as opposed to paper -- health records.

Note that all participating practices were part of a regional health network committed to public reporting of care and outcome measures and that results favoring electronic health records were consistent across different insurance plans.

Use of electronic health records (EHRs) for patients with diabetes improves achievement of care and outcomes targets, researchers found.

Significantly more centers in the greater Cleveland area met standards for diabetes care and outcomes when they used EHRs compared with paper-based systems (P<0.001 and P=0.005, respectively), Randall Cebul, MD, of Case Western Reserve University, and colleagues reported in the Sept. 1 issue of the New England Journal of Medicine.

The findings "support the premise that federal policies encouraging the meaningful use of EHRs may improve the quality of care across insurance types," they wrote.

Cebul and colleagues acknowledged that previous studies haven't shown many advantages for quality-related outcomes with electronic records over traditional paper-based systems, though they noted several methodological limitations with those studies.

So to clarify the issue, they compared achievement of care and outcomes standards among 27,207 diabetic patients at 46 practices in a health system in Cuyahoga County in northeastern Ohio that were using either EHR or paper records between July 2009 and June 2010.

The researchers looked at four standards of care and five standards of intermediate outcomes. Care standards included receipt of glycated hemoglobin (HbA1c) values, testing for urinary microalbumin or prescribing an ACE inhibitor or an angiotensin receptor blocker (ARB), an eye examination for diabetic retinopathy, and giving a pneumococcal vaccine.

The researchers noted that 38% of patients were in safety-net practices, which attend to vulnerable populations.

In unadjusted analyses, the researchers found that 50.9% of patients at EHR sites received care that met all four standards, compared with 6.6% of those at paper-based sites. Similarly, 43.7% of EHR patients met at least four of five outcomes standards, compared with 15.7% of patients at paper-based centers.

After adjustment, achievement of composite standards for care was 35.1 percentage points higher at EHR sites than paper-based sites (P<0.001).

Cebul and colleagues noted that the results were similar for safety-net practices, with an adjusted 29.8 percentage point difference in care (P<0.001) and a 9.7 percentage point difference in outcomes standards (P=0.002).

Trends were significant across all insurance types, but the researchers noted that it was weakest among the uninsured, "a vulnerable group that is under-represented in other studies of EHRs and quality of care."

In further analyses, the researchers saw greater improvement in care and outcomes every year for EHR facilities than for paper-based ones, with a difference of 10.2 percentage points in annual improvement for care standards (P<0.001) and a 4.1 percentage point increase in annual improvement for outcomes standards (P=0.02).

They wrote that "as in other studies, the association was stronger for care ... than for outcomes, which also require supportive home and neighborhood environments, active patient engagement, and other resources that foster adherence to prescribed regimens."

They also noted that their results contrast with recent studies finding no association between EHR use and quality of care, but pointed out methodological limitations with the data sets used in those studies. Some, for instance, relied on older data from the National Ambulatory Medical Care Survey. Also, their analysis accounted for safety-net practices as well.

Still, their study was limited by observational data which make it subject to selection bias, by use of practices in a network committed to public reporting of care and outcome measures, and by geographic location, which may limit its generalizability outside of the Cleveland area.

The researchers are active participants in Better Health Greater Cleveland, a regional collaborative supported by the Robert Wood Johnson Foundation and other sources.

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